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Comment les hôpitaux cachent leurs déficits
Obligés de présenter des budgets en équilibre avec des crédits fixés d’avance et très contraints, les hôpitaux multiplient les irrégularités comptables pour dissimuler les déficits ou gonfler artificiellement les recettes. Des pratiques qui ont toutes les chances de perdurer malgré les efforts de contrôle que la Cour des comptes appelle de ses voeux.
Mis en ligne le 13 septembre 2007
A LA UNE
Soigner, les hôpitaux savent. Compter, en revanche, semble beaucoup moins évident. En repassant au peigne fin la comptabilité du CHU de Caen (Basse-Normandie), la chambre régionale des comptes a ainsi levé pas mal de lièvres. En moyenne, de 2000 à 2005, ce sont 6 à 8 millions d’euros de dépenses qui ont été oubliées chaque année. Après rectification, tous les bilans ont basculé dans le rouge. Soumis au même traitement, le centre hospitalier de la Côte Basque (Pyrénées-Atlantique) a dû dire adieu aux excédents affichés de 1999 à 2003 tandis que celui de Villeneuve-sur-Lot (Lot-et-Garonne) devait réduire de 17% ses résultats.
En 2005, plus du quart des hôpitaux ont eu recours à des reports de charges « sauvages » pour un montant global évalué à 86 millions d’euros.
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De 2004 à 2006, la Cour des comptes et 19 chambres régionales ont épluché les comptes de 69 hôpitaux dont 11 CHU. Même réduit par rapport aux 1 118 établissements publics de santé que compte le pays, l’échantillon n’a laissé aucun doute. Les hôpitaux multiplient les astuces comptables pour masquer le plus souvent des déficits mais aussi parfois des excédents. Même assouplie, la contrainte de devoir présenter en fin d’année un budget équilibré reste la cause essentielle de ces manoeuvres. Dans son rapport sur la sécurité sociale publié en septembre 2007, la Cour des comptes en dresse une liste exhaustive.
Pour masquer les déficits, l’une des pratiques les plus courantes consiste à reporter des charges relative à une année sur les suivantes. Depuis mai 2004, le centre hospitalier de Chalon-sur-Saône remet ainsi en permanence à plus tard le paiement de la taxe sur les salaires. En janvier 2006, la dette accumulée s’élevait à 6,1 milions d’euros. En 2004, ce sont 685 millions d’euros que l’ensemble des hôpitaux ont transféré sur 2005, soit 43% de plus qu’en 2003.
A ces mouvements officiels, il faut encore ajouter les reports « sauvages » qui ne sont enregistrés nulle part ! La chambre régionale des comptes de Midi-Pyrénées a ainsi découvert que le CHU de Toulouse en avait fait un véritable système : plus de la moitié des factures payés début 2003 avaient en fait été émises en 2002. En 2005, plus du quart des hôpitaux ont eu recours à des reports de charges « sauvages » pour un montant global évalué à 86 millions d’euros.
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Le pari de la souplesse
Pour éviter le recours à des astuces qui faussent les comptes, la règle de l’équilibre obligatoire a été assouplie en 2006. Désormais, les hôpitaux pourront utiliser un état prévisionnel de recettes et de dépenses (EPRD) où ils feront figurer des « crédits évaluatifs » au lieu du « budget limitatif » utilisé jusqu’en 2005. La Cour des comptes note avec satisfaction que de nombreux hôpitaux, dont 61% des CHU, ont publié en 2006 des EPRD affichant des déficits. Un gage de sincérité encourageant mais qui reste... prévisionnel.
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Autre astuce pratique pour minorer les déficits : ne pas enregistrer comme des pertes des créances pourtant irrécupérables. Au 31 décembre 2005, elles atteignaient le montant astronomique de 205 millions d’euros et permettaient surtout aux 1 118 hôpitaux français d’afficher un excédent global de 185 millions d’euros au lieu d’une perte de 20 millions, beaucoup plus proche de la réalité aux yeux de la Cour des comptes.
Les recettes aussi peuvent astucieusement venir en aide aux budgets défaillants. Certains hôpitaux utilisent ainsi une disposition de la tarification à l’activité (T2A) qui leur permet, au dernier trimestre de l’année, d’enregistrer dans leurs comptes des recettes provenant de la sécurité sociale sans les avoir déjà encaissées. En bonne logique, elles sont passées de 168 millions d’euros en 2004, année précédent l’entrée en vigueur de la T2A, à... 1,5 milliard d’euros en 2005 !
Pour mettre un terme à cette escalade, la Cour des comptes mise sur trois outils. Le premier s’appelle HELIOS. Ce système informatique va relier directement les ordinateurs de « l’ordonnateur » des dépenses (les hôpitaux) avec ceux des comptables publics chargés de les vérifier. Au passage, il mènera des contrôles automatisés afin de détecter plus rapidement les erreurs et les omissions. Très attendu, HELIOS risque cependant de ne pas tenir toutes ses promesses. Non seulement sa mise en orbite a été reportée fin 2008 mais il n’est pas encore sûr que les systèmes informatiques des hôpitaux soient aménagés pour le prendre en charge.
Les directeurs des hôpitaux et les comptables publics peuvent aussi désormais passer des conventions afin de clarifier leurs rapports et assurer ainsi la sincérité des comptes. Un espoir ténu au vu des chiffres. Fin 2006, une dizaine de conventions seulement ont été conclues et très peu abordaient les points sensibles susceptibles de garantir une comptabilité fiable.
Troisième et dernier outil, le compte financier unique. Jusqu’en 2006, la comptabilité de chaque hôpital était en effet retracée dans deux documents différents : le compte administratif présenté au conseil d’administration de chaque établissement de santé et un compte dit de gestion élaboré par le comptable public. Mais là encore, les promesses risquent de ne pas être tenues : hôpitaux et comptables ne sont ni tenus de l’élaborer ensemble ni de le signer conjointement comme dans la plupart des établissements publics. Autant de bonnes intentions qui ne menacent guère des pratiques désormais bien ancrées.
Gilmar S. MARTINS
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